Medicare Victories Possible If Clinicians Enter the Fray

Complaining about the idiosyncratic payment policies of the nation’s Medicare insurance carriers has become a common occurrence among psychiatrists who treat elderly patients.

But attorney Seth Stein, J.D., maintains that while there is plenty of reason for psychiatrists to be distressed about Medicare reimbursements, considering the “enormous variability” in how these carriers pay for psychiatric care, he is troubled by the fact that these erratic policies are going “unchallenged and tolerated by psychiatrists.”

As executive director and chief counsel of the New York State Psychiatric Association, Stein has for many years helped resolve disputes between the medical director of New York’s Medicare carriers and unhappy psychiatrists in his state, giving him substantial experiences from which he draws this conclusion.

Psychiatrists are not powerless, however, when they believe they are the victim of a Medicare carrier’s incorrect payment decision, Stein told psychiatrists at an APA annual meeting workshop in New Orleans in May. The “likelihood of success is extraordinarily high—as much as 80 percent to 90 percent”—if psychiatrists would just take the time to initiate the appeals process that all carriers have, he said.

He suggested that a belief that “they are too much trouble to pursue” and a fear of being plagued with nuisance reviews are the main culprits keeping psychiatrists from pursuing their appeals rights in Medicare payment disputes. He added that as for the latter concern, “carriers don’t work that way.”

The first step in appealing a denied claim, Stein said, is to ask the carrier to reconsider the denial. That rarely brings about the result the psychiatrist hopes for, he noted.

Carrier hearings are the next level of appeal, and Stein pointed out that the disputed claims must have a value of at least $100, but clinicians have the option of combining several disputed claims in a single appeal. He cautioned the psychiatrists at the workshop that to take advantage of this appeal mechanism, they must begin the process within six months of the original claims denial. Unfortunately this six-month limit reduces the chances that a clinician will be able to aggregate the claims, he noted. Psychiatrists can participate in the hearing process in person, by telephone, or in writing.

The hearing officer at this level of appeal is almost always an employee of the insurance company, he said.

If a clinician’s case gets nowhere at the carrier hearing, he or she can then appeal to an administrative law judge (ALJ), who is independent of the carrier and thus the carrier’s interpretation of the Medicare rules at issue. Unfortunately, Stein noted, this process can take 12 to 18 months to work through.

At this phase, however, the carrier does not participate: “It’s you and the judge,” he said, “and if you put your case together well, there is a high probability of success.” In addition, multiple clinicians—though not partners—can combine appeals based on the same grounds to the ALJ, which could strengthen a case.

Because of this ability to aggregate claims, Stein emphasized that it is crucial for individual psychiatrists to report Medicare reimbursement problems to either APA or their district branch, so the organizations can assist in aggregating those disputed claims.

He cautioned, however, that while extremely influential, the ALJ’s decision is not binding on the Medicare carrier.

Ellen Jaffe, of APA’s Office of Healthcare Systems and Financing, also stressed that department’s readiness to help members resolve Medicare disputes. “We have found,” she said, “that if we go to HCFA [the federal Health Care Financing Administration] with good data to support our view of a problem claim, they are usually very responsive.”

She reminded audience members that APA has a Medicare Advisory Committee with a representative from every state. The committee, chaired by Edward Gordon, M.D., who also chaired the annual meeting workshop, deals with Medicare carriers throughout the country and coordinates activities in which psychiatry and the carriers intersect.

One of the country’s largest Medicare carriers was represented at the workshop in the form of its medical director, who gave psychiatrists some inside advice and perspective on the reimbursement process.

Gerald Rogan, M.D., is the Medicare carrier director for National Heritage Insurance Company (NHIC), which is the Medicare carrier for California and the New England states. NHIC, Rogan noted, pays 11 percent of the country’s Medicare claims.

Rogan, who previously practiced family and emergency room medicine, said that his philosophy regarding psychiatric benefits and claims is that they should be evaluated by the same standards as those for diabetes or cardiac care, for example, though he added that he realizes he “can’t do anything about the lack of psychotherapy parity” in Medicare.

He stated that he views his job as “interpreting the law in favor of getting the most money for doctors” who submit Medicare claims. He strongly urged his audience to “maintain vigilance to make sure that the carrier follows the rules.” And if psychiatrists believe their local carrier has failed to do so, they should let APA know so it can pursue it with the carrier, HCFA, or Congress.

What the Medicare program is trying to do, Rogan asserted, even when carriers question claims or audit a physician, “is to find ways to ensure that you can get paid fairly under the law.”

To monitor just how fairly his or her carrier does follow the federal rules, “Every psychiatrist should get a copy of the Medicare carrier’s policies,” Stein stressed, “and should know just what the policies of the carrier are.”